Wednesday, October 31, 2007

People who suffer from chronic headaches have been known to try all sorts of pills and home remedies. But cayenne peppers?

Behind the folk wisdom is capsaicin, the active ingredient in cayenne. It is said to bring relief by depleting Substance P, a neurotransmitter that helps transmit pain impulses. Sounds unlikely, but a number of studies have tested the claim, and most have found evidence to support it.

One prominent study was published in 1998 in The Clinical Journal of Pain by researchers in the department of anesthesia and critical care at the University of Chicago. In it, the researchers analyzed data from 33 prior studies and found that capsaicin seemed to work better than placebos for headaches occurring in clusters.

But simply eating hot sauce isn't going to help. Most studies suggest that capsaicin works just when applied topically. A study by researchers at Massachusetts General Hospital recruited sufferers of chronic headaches and randomly split them. One group had small amounts of diluted capsaicin applied inside the nose for a week. The other received placebo. The study found "a significant decrease in headache severity in the capsaicin group," but not the placebo group. Other studies, including one this year, published similar results.

Tuesday, October 30, 2007

Nociceptive pain results from the detection of intense or noxious stimuli by specialized high-threshold sensory neurons (nociceptors), a transfer of action potentials to the spinal cord, and onward transmission of the warning signal to the brain. In contrast, clinical pain such as pain after nerve injury (neuropathic pain) is characterized by pain in the absence of a stimulus and reduced nociceptive thresholds so that normally innocuous stimuli produce pain. The development of neuropathic pain involves not only neuronal pathways, but also Schwann cells, satellite cells in the dorsal root ganglia, components of the peripheral immune system, spinal microglia and astrocytes. As we increasingly appreciate that neuropathic pain has many features of a neuroimmune disorder, immunosuppression and blockade of the reciprocal signaling pathways between neuronal and non-neuronal cells offer new opportunities for disease modification and more successful management of pain.

WASHINGTON - Devil's Revenge. Spontaneous Combustion. Hot sauces have names like that for a reason. Now scientists are testing if the stuff that makes the sauces so savage can tame the pain of surgery.

Doctors are dripping the chemical that gives chili peppers their fire directly into open wounds during knee replacement and a few other highly painful operations.

Don't try this at home: These experiments use an ultra-purified version of capsaicin to avoid infection — and the volunteers are under anesthesia so they don't scream at the initial burn.

How could something searing possibly soothe? Bite a hot pepper, and after the burn your tongue goes numb.

The hope is that bathing surgically exposed nerves in a high enough dose will numb them for weeks, so that patients suffer less pain and require fewer narcotic painkillers as they heal.

"We wanted to exploit this numbness," is how Dr. Eske Aasvang, a pain specialist in Denmark who is testing the substance, puts it.

Chili peppers have been part of folk remedy for centuries, and heat-inducing capsaicin creams are a drugstore staple for aching muscles.

But today the spice is hot because of research showing capsaicin targets key pain-sensing cells in a unique way. California-based Anesiva Inc.'s operating-room experiments aren't the only attempt to harness that burn for more focused pain relief.

Harvard University researchers are mixing capsaicin with another anesthetic in hopes of developing epidurals that wouldn't confine women to bed during childbirth, or dental injections that don't numb the whole mouth. And at the National Institutes of Health, scientists hope early next year to begin testing in advanced cancer patients a capsaicin cousin that is 1,000 times more potent, to see if it can zap their intractable pain.

Nerve cells that sense a type of long-term throbbing pain bear a receptor, or gate, called TRPV1. Capsaicin binds to that receptor and opens it to enter only those pain fibers — and not other nerves responsible for other kinds of pain or other functions such as movement.

These so-called C neurons also sense heat; thus capsaicin's burn. But when TRPV1 opens, it lets extra calcium inside the cells until the nerves become overloaded and shut down. That's the numbness.

"It just required a new outlook about ... stimulation of this receptor" to turn those cellular discoveries into a therapy hunt, says NIH's Dr. Michael Iadarola.

Enter Anesiva's specially purified capsaicin, called Adlea. Experiments are under way involving several hundred patients undergoing various surgeries, including knee and hip replacements. Surgeons drip either Adlea or a dummy solution into the cut muscle and tissue and wait five minutes for it to soak in before stitching up the wound.

Among early results: In a test of 41 men undergoing open hernia repair, capsaicin recipients reported significantly less pain in the first three days after surgery, Aasvang reported this month at a meeting of the American Society of Anesthesiologists.

In a pilot U.S. study of 50 knee replacements, the half treated with capsaicin used less morphine in the 48 hours after surgery and reported less pain for two weeks.

Ongoing studies are testing larger doses in more patients to see if the effect is real.

There's a huge need for better surgical pain relief, says Dr. Eugene Viscusi, director of acute pain management at Thomas Jefferson University in Philadelphia, one of the test sites. Morphine and its relatives, so-called opioid painkillers, are surgery's standby. While they're crucial drugs, they have serious side effects that limit their use.

Specialists are watching the capsaicin research because it promises a one-time dose that works inside the wound, not body-wide, and wouldn't tether patients to an IV when they're starting physical therapy.

"There's been an enormous effort to try and develop alternatives to opioids with the same strength but not too much success," adds Dr. Clifford Woolf of Harvard and Massachusetts General Hospital. "We think we're moving toward it."

His team is trying a different approach: Standard lidocaine injections numb all the surrounding tissue. Woolf and colleagues slipped lidocaine inside just pain-sensing neurons, by opening them with a tiny dose of capsaicin. Rats given the injections ran around normally while not noticing heat applied to their paws, they reported in the journal Nature this month.

That's years away from trying in people, and would have to be done in a way to avoid even a quick capsaicin burn.

In a third approach, Iadarola and NIH colleagues hope to soon test a capsaicin cousin called resiniferatoxin in advanced cancer patients whose pain no longer is relieved by opioids. Injections into the spinal columns of cancer-riddled dogs did more than temporarily numb — it severed some nerve connections.

Sunday, October 28, 2007

Fortunately, no one seems to have noticed that I wrote last week's column with one eye closed. I also had the lights in my office off, the shades drawn and the thermostat turned up to about 85 degrees.

All this because I had a migraine. In fact, I was on day six of a migraine that would, by day seven, have me dissolving into tears in between the taped segments of my radio show. (Think Holly Hunter. Think "Broadcast News." The show went on, seamlessly.)

I was suffering like this because I was Taking Control of my life. I'd recently read "Heal Your Headache," by the Johns Hopkins University neurologist David Buchholz. And now I was following his "1-2-3 Program for Taking Charge of Your Pain."

In Dr. Buchholz's view, chronic migraine sufferers like me — I average around seven to twelve headaches a month — are, very often, victims of their own past treatment successes. Triptans, the new-ish class of drugs that bind to serotonin receptors and can work wonders when taken early in migraine attacks, cause rebound headaches, he says, if you take them more than two days a month. So do over-the-counter painkillers and stronger stuff like codeine and oxycodone.

Step 1 in his plan, then, involves removing such "quick fix" drugs from your life. Step 2 is about recognizing your migraine "triggers" and removing the ones – like certain foods, alcohol and caffeine – that you can do something about. (As opposed to the ones – like changes in barometric pressure, work deadlines and mothers-in-law — that you can't do anything about.) Step 3 is daily preventive medicine – but the idea, in Buchholz's book, is that if you do well enough at Steps 1 and 2, you might not have to go to Step 3.

I am already there. And I have been trying to get out.

I've had migraine headaches since the age of 8. When I was younger, they were severe, but infrequent. When I turned 35, they turned chronic. They were — at best, when the triptans were working — fatiguing. At worst, they sent me to the emergency room. A few years ago, they got much better for a while when I started taking amitriptyline, a tricyclic antidepressant (formerly known as Elavil) that is now given, in low doses, as a migraine preventative.

I didn't like the amitriptyline. It made me gain weight. It made me sleepy. It made me think of mental patients shuffling down the corridors of state hospitals in the 1950s.

I wasn't willing to take the higher doses of amitriptyline that came to be needed, over time, to allow the drug to really work. I liked the idea that, through supreme force of will, I could free myself from the iron grip of Big Pharma.

So I followed Buchholz's prescriptions. I stopped taking my Relpax, a triptan, and put away my Prontalgine, the codeine- and caffeine-containing, French over-the-counter headache remedy that I use when the Relpax doesn't work.

For a couple of weeks, I was ravenously hungry, cranky, spaced out and vaguely, deprivedly resentful. But I felt, headache-wise, somewhat improved. I had six or nine migraines, but they were less severe. And, once I got used to it, I came to almost enjoy being on my diet, exploring my capacity for hunger and self-abnegation, obsessing over what foods I could eat, and how, and when. At the very least, the diet made my friends happy. Renouncing food, renouncing pills, is so often, in our time, seen as the right and righteous, pure and wholesome thing to do.

And then the headaches returned, with a vengeance.

Earlier this week, I went to see my neurologist, who for months has been trying to get me to increase my dosage of amitriptyline or go on topamax, an anti-seizure drug that also prevents migraines.

"Are you enjoying your suffering?" he asked me.

Eagerly pocketing my topamax script, I asked him if he thought that food elimination could hold out any last hope.

Maybe, he said, smirking down into his notes; you never know. "You could always go up to Baltimore and ask Dr. Buchholz."

Many people who take daily medications come at some point to hate them. Teenagers with ADHD routinely rebel against their meds. Long-term users of anti-depressants risk relapse because they can no longer stand the way the drugs make them feel.

Some people do manage, through diet and exercise, or by protecting themselves from their worst "triggers," to free themselves from their drugs. But many can't do it. Many find they can't accept living in the compromised condition that drug-free existence requires.

A smart high school girl I know switched a few years ago from a mainstream school, where she was struggling with dyslexia and ADHD, to a school that specializes in teaching kids with severe learning disabilities. Being there has permitted her to function without her ADHD meds. But now she's bored. She's dispirited by the lack of academic challenge and she wants out, because she's afraid that, without academic challenges, she won't be able to get into a mainstream college.

That's the tradeoff: taking daily drugs, or living a life that feels not quite worth living.

Halloween is coming, and Emilie and I have a ritual: While trick or treating, we eat exactly one piece of candy after every house. She gives me the Snickers bars. She keeps the Hershey's Kisses and the M&Ms. We split the caramel creams and the Starbursts and pawn the dark chocolate off on her sister, Julia.

This year she's anxious. I'm not eating chocolate. Or peanuts. This week, with her babysitter, she baked me a cake, white with white frosting, sprinkles, multi-colored flowers and candy corn. But, she asked me, what will happen on Halloween?

I told her not to worry; I'd eat my Snickers bars.

In fact, I think that I'll sanctify Halloween by eating every single forbidden food on the migraine diet, all in the space of a couple of hours.

Saturday, October 27, 2007

The Office of Research on Women's Health (ORWH) at the National Institute's of Health (NIH), in partnership with other federal and non-federal partners, announced the launch of the "Vulvodynia Awareness Campaign" on October 24, 2007.

Vulvodynia, also referred to as "the pain down there" or "feminine pain," is chronic discomfort or pain of the vulva, which is the area around the outside of the vagina. It is a persistent condition for which there is no apparent cause and no single effective treatment. Vulvodynia can have stressful effects on every day life and relationships. A lack of sufficient consumer and health care provider information may contribute to a delayed diagnosis and the ultimate long-term suffering of vulvodynia patients.

Researchers estimate that as many as 18 percent of women will experience symptoms consistent with vulvodynia. Many women suffer with unexplained vulvar pain for months — even years — before a correct diagnosis is made and an appropriate treatment plan is determined. Studies have shown that almost half of the women with symptoms chose not to seek treatment, even when these symptoms limited sexual intimacy. (Bachmann et. al, 2006).

"The time has come to talk openly and directly about vulvodynia — its symptoms, diagnosis, and treatment — so that the quality of life of sufferers of this condition can be improved," said Vivian W. Pinn, M.D., Director, Office of Research on Women's Health, NIH.

There is currently no cure for vulvodynia. But there are treatments for some of the symptoms. Some current treatments include local pain relievers (medications), physical therapy, changes in diet, and drug treatment. Because each woman's symptoms may be different, no one treatment works all the time or is right for everyone.

The NIH Office of Research on Women'' Health (ORWH) hopes by combining forces with partners such as advocacy groups, health care practitioners, research organizations, and federal and non-federal entities, there will be increased awareness and understanding of this important medical condition for women. Over the years, ORWH has helped expand the scope of women's health research. This research and consequent dialogue have led to better decision-making regarding treatment options for a wide range of medical conditions. Many issues that were or may still be considered "sensitive" for women to discuss with their health care providers resulted too often in women suffering in silence. For example, breast cancer, menopause, urinary incontinence, cervical cancer, sexually transmitted infections, and uterine fibroids are a few examples of conditions that affect women and that only over recent years have women begun to feel more comfortable discussing openly. ORWH continues its efforts to bring these women's health issues into the public arena.

Wednesday, October 24, 2007

Smoking large amounts of cannabis for therapeutic reasons may increase rather than reduce pain, a US study suggests.

The pain-relieving qualities of cannabis have long been hailed, and several countries have made it available for medicinal purposes.

But quantity is key, according to the study in the journal Anesthesiology.

University of California researchers found moderate use had the greatest impact on pain in 15 volunteers, while large doses actually made pain worse.

The team recruited 15 healthy volunteers, in whom pain was induced by injecting capsaicin - the "hot" chemical found in chilli peppers - under their skin.

They were then given cannabis to smoke. The strength of the dose was determined by the tetrahydrocannabinol content, which is the main active chemical in cannabis.

Some of the volunteers were given a placebo.

High, but in pain

Five minutes after smoking the drug, none of the doses had any effect on the pain felt.

But 45 minutes later, those who had smoked the moderate dose said their pain was much better, while those who consumed high doses said it had got worse.

They did, however, feel "higher" than counterparts who had taken moderate doses.

Dr Mark Wallace, the lead researcher, said the findings could have implications for the way medicinal cannabis was offered, both in pure and drug form.

Some experts are concerned that results on healthy volunteers could not be translated into how cannabis works in the bodies of those with cancer or multiple sclerosis, for whom the drug is increasingly seen as a potential form of pain relief.

Dr Laura Bell, of the MS Society, said: "Many people with MS report benefits to symptoms such as pain from taking cannabis, however studies to date on the effects of cannabis on pain are small and difficult to draw firm conclusions from.

"We would be interested to see the results from larger scale studies focused on people with MS."

Tuesday, October 23, 2007

Since meeting at the Academy of Media Arts in Cologne in the late 90s media artists Roman Kirschner, Volker Morawe and Tilman Rieff have been working together under the name fur, a group that, in their own words "stands for the re-staging of computer-entertainment based on multisensory interfaces" - or, in other words, work to decontextualise videogames and other forms of computer based amusements by changing the way they are used.

By changing the interfaces used to interact, the creations of fur go beyond "visual navigation, manual control and massive single-user isolation" to become something completely new, not only within the world of videogames, but also within the world of art. Their most famous work is the PainStation, from 2001- a game of Pong within a specially designed cabinet that would whip and shock players hands, often causing tangible wounds, which fur describe as a " a contemporary dueling system".

**

Reaction to the machine on the PainStation website's guestbook is varied, ranging from the good:

"Greatest gaming console the world has ever known. Me and two of my friends visited London last summer after our graduation. We ended up going to the V&A's TOUCH exibit where we thankfully found the original PainStation. We couldn't or at least I couldn't get enough of plaing the game, I believed that I stood there playing various spectators for over two hours."

To the bad:

"This is so DUMB… are people so bored that they want to get themselves hurt??? Then again, there are movies of dudes hitting eachother with things for FUN so i'm not that surprised people would also find this Painstation thing cool."

**

Can you explain what the PainStation is, and what it does?

It's a two player table console that dishes out real pain to bad player's. People have to place one hand on a so called "PainExecutionUnit" and play an enhanced version of the game "Pong". If one player misses the ball he gets a dose of punishment in the form of electricity, heat or a small rotating whip. The first player to pull back his hand looses.

What was the goal behind the PainStation, and do you feel you've met this?

The very basic goal was to make use of the electronic interface device that my girlfriend brought from USA and that was lying around for half a year. The artistic goal was to bring a more physical experience to computer games.

How do you feel the reaction to the PainStation has been? In particular, how does it feel to have won an International Media Art Award for your work?

We have always felt like the traditional art world considers our work as "child's play", so winning the price was quite an honor for us because it sort of proved that we have to be taken seriously! Hehe…

Finally, why do you think there's such a fascination with the idea of a videogame causing physical pain?

It's a completely new experience. The threat of being punished alone puts all your senses on red alert. Then there's the back and forth of your opponent suffering, screaming while the next rally might cause some whipping and shocking on your side. It's a constant change between satisfaction and punishment, fun and pain.

Monday, October 15, 2007

Differences in Pain Between Women and MenEpidemiology of Pain in WomenSex Differences in Pain - Basic Science FindingsSex Hormones and PainGender and the Brain in PainPain During PregnancyObstetric PainDysmenorrhea: Contemporary PerspectivesChronic Pelvic PainEndometriosis and its Association with Other Painful ConditionsVulvodyniaIrritable Bowel Syndrome (IBS)Fibromyalgia Syndrome (FMS)Sex and Gender Differences in Orofacial PainPain in Women in Human Immunodeficiency Virus (HIV/AIDS)Pain in Women in Developing CountriesViolence Against Women (Gender-based Violence)Children with Chronic Pain: Sex and Gender Differences

International Association for the Study of Pain (IASP) Declares the Global Year Against Pain in Women

'Real Women, Real Pain' Campaign Highlights the Suffering Caused by Disparities in Pain Recognition and Treatment in Women Around the World

Today, the International Association for the Study of Pain (IASP) has declared 2008 the Global Year Against Pain in Women to draw attention to the significant impact of chronic pain on women and the need for more effective care. Lack of awareness of pain issues affecting women and gender disparities in treatment and research contribute to the suffering of millions of women.

"Chronic pain affects a higher proportion of women than men, but unfortunately they are also less likely to receive treatment compared to men due to various cultural, economic and political barriers," said Troels S. Jensen, MD, President of IASP, Professor of Experimental and Clinical Pain Research, University of Aarhus, Aarhus, Denmark. "IASP hopes to provide a voice to these women by drawing attention to this global issue as a first step towards reducing pain and suffering of women around the world."

Women appear to experience pain differently than men, although the reason is not entirely understood. It is believed that this difference is due to numerous biological reasons including genetic, hormonal and pharmacological factors/influences. In addition, psychosocial and cultural disease factors/influences play an important role in how women experience pain.

Taking Action

Over the next year, the 'Real Women, Real Pain' campaign will educate the public, healthcare providers and government leaders/agencies about the lack of diagnosis and adequate treatment of chronic pain in women.

This will help to:

- Increase awareness of pain conditions predominantly affecting women and help women and healthcare providers recognize signs and symptoms- Raise awareness of disparities between female/male pain issues- Empower women to become advocates for themselves and others, by encouraging them to affirm their pain is real and seek proper treatment- Increase female-specific research- Encourage the development of new female-specific treatment options

To further these objectives, IASP will initiate a number of national and local activities in conjunction with their 69 local chapters worldwide. A special issue of the IASP journal Pain will be dedicated to pain in women in November 2007. The IASP website will also feature campaign information including local IASP chapter initiatives.

Gender Inequalities in Health Care

Certain pain conditions commonly affecting women often do not receive adequate attention as historically medical research has heavily relied on male populations and conditions affecting them. The result of this male-centric research approach is that women continue to be treated based on studies in which they may not have been adequately represented.Access to healthcare services, particularly in poverty stricken areas of the developing world, can act as a barrier for women seeking help for pain conditions.

Cultural factors also influence a woman's likelihood of seeking treatment for medical conditions, including pain. For example, in many cultures, women believe that their suffering is part of their role in society. Additionally treatment by a male healthcare provider may also bring shame to a woman's family, forcing her to go without treatment.Women may also encounter situations where physicians do not believe their pain is real.

"In order to promote change around the world, we need to raise awareness of pain disorders predominantly affecting women, increase research into these conditions and effective treatment options, as well as improve access to needed therapies," said Beverly Collett, MBBS, FRCA, IASP Council member and Consultant in Pain Medicine at Leicester Royal Infirmary, UK.

IASP would like to recognize Pfizer Inc as a sponsor of the Global Year Against Pain in Women and thank them for supporting efforts to promote education on this important issue.

For more information on The Global Year Against Pain and Women, upcoming initiatives around the world, please visit http://www.iasp-pain.org.

Friday, October 12, 2007

This site is for anyone with a professional or personal interest in pain and analgesia. It is firmly based in the principles of evidence-based medicine and has pulled together systematic reviews with pain as an outcome.

Bandolier's scientific home is the Pain Research Group, based in Oxford, where thinking about evidence based matters has taken place since 1992. The group has pioneered work on systematic reviews in pain and anaesthesia, and has helped develop research methods in many other areas (statins, erectile dysfunction, migraine, genital warts and prostatic hyperplasia). The group has produced over 100 systematic reviews including contributions to the Cochrane Library.

Thursday, October 11, 2007

NEW YORK — If your hipbone is connected to your BlackBerry or your thighbone is connected to your cellphone, those vibrations you're feeling in the car, in your pajamas, in the shower, may be coming from your headbone.

Many mobile phone addicts and BlackBerry junkies report feeling vibrations when there are none, or feeling as if they're wearing a cellphone when they're not.

The first time it happened to Jonathan Zaback, a manager at the public relations company Burson-Marsteller, he was out with friends and showing off his new BlackBerry Curve.

"While they were looking at it, I felt this vibration on my side. I reached down to grab it and realized there was no BlackBerry there."

Zaback, who said he keeps his BlackBerry by his bed while he sleeps, checks it if he gets up in the middle of the night and wakes to an alarm on the BlackBerry each day, said this didn't worry him.

"As long as it doesn't mean a tumour is growing on my leg because of my BlackBerry, I'm fine with it," he said. "Some people have biological clocks, I might have a biological BlackBerry."

Some users compare the feeling to a phantom limb, which Merriam-Webster's medical dictionary defines as "an often painful sensation of the presence of a limb that has been amputated."

"Even when I don't have the BlackBerry physically on my person, I do find myself adjusting my posture when I sit to accommodate it," said Dawn Mena, an independent technology consultant based in Thousand Oaks, Calif. "I also laugh at myself as I reach to unclip it — I swear it's there — and find out I don't even have it on."

Research in the area is scant, but theories abound about the phenomenon, which has been termed "ringxiety" or "fauxcellarm."

Anecdotal evidence suggests "people feel the phone is part of them" and "they're not whole" without their phones, since the phones connect them to the world, said B.J. Fogg, director of research and design at Stanford University's Persuasive Technology Lab.

"As human beings, we're so tapped into our community, responsiveness to what's going on, we're so attuned to the threat of isolation and rejection, we'd rather make a mistake than miss a call," he said. "Our brain is going to be scanning and scanning and scanning to see if we have to respond socially to someone."

In certain circles, phantom vibrations are a point of pride.

"Of course I get them," said Fred Wilson, a managing partner of Union Square Ventures, an early-stage venture capital firm based in New York. "I've been getting them for over 10 years since I started with the pager-style BlackBerry."

For others, it's one more tech irritation.

Jeff Posner, president and owner of e-ventsreg.com in New Jersey, which allows users to register and check in for trade shows and other events, stopped wearing his BlackBerry on his belt because of regular false alarms. He put it in the chest pocket of his shirt but found that was worse, because now his phone dials automatically, which has created a new annoyance: It always calls the same person, he said.

"Phones have favourite friends," he said. "It's like your phones have a thing for each other. Of course, it's a female friend, so my wife is like, 'You're calling her all the time.'"

Complicating things further, his own phone is his sales manager's favourite friend.

"Dilbert" cartoonist Scott Adams wrote on his blog, dilbert.org, that he feels the phantom vibrations, "about 10 times per day" and thinks "'Ooh, it's an e-mail with good news!' So far, the only good news is that my pocket is vibrating, and that's OK because it gives me hope that the condition might spread to the rest of my pants."

Jake Ward, a former press secretary for Sen. Olympia Snowe and current director of Qorvis Communications Inc., a public relations company in Washington, D.C., said he switched his BlackBerry from his hip to his jacket pocket six months ago, but still feels it there.

"Aftershocks," he said.

He also claims to "pre-feel" a new message or call. "I'll feel it, look at it. It's not vibrating. Then it starts vibrating," he said. "I am one with my BlackBerry."

For some, it's a matter of projecting hope onto their wireless device. Don Katz said he came out of retirement to work as director of wireline product management at SpinVox Inc. because he was so impressed with the company's voice-mail product. He worked on its recent launch at SaskTel, the telecom company in Saskatchewan, Canada. That may be why, on a recent train trip to New York, he kept checking his phone, because he said he was sure it was vibrating.

Clinicians Shouldn't Routinely Order Imaging and Other Diagnostic Tests

PHILADELPHIA, Oct. 2, 2007 - The American College of Physicians (ACP) and the American Pain Society (APS) today released joint guidelines on diagnosing and treating low back pain.

About one in four Americans reported having low back pain in the past three months and about l7.6 percent of all adults reported at least one episode of severe acute low back pain within the previous year, according to several studies. Other studies show that most people's low back pain will improve within one month, regardless of treatment. Treatments range from doing nothing to spinal surgery.

In 2006, ACP and APS convened a multidisciplinary panel of experts to develop questions and the scope of an evidence report on low back pain, to review its results and come up with recommendations for primary care physicians to diagnose and treat low back pain.

The recommendations, published in the Oct. 2, 2007, issue of Annals of Internal Medicine, include an algorithm to guide clinicians in obtaining and interpreting information during the first patient visit and place patients into one of three general categories:

Back pain potentially associated with another specific cause, such as cancer.

The recommendations say that clinicians should not routinely order imaging or other diagnostic tests such as X-rays, CAT scans, and MRIs for patients with nonspecific low back pain. They should reserve these tests for patients who have severe or progressive neurologic deficits or suspected underlying conditions, such as cancer or infection.

The joint ACP-APS guidelines are designed for primary care physicians and other clinicians and do not address invasive therapies performed by specialists. The American Pain Society will publish a separate guideline covering invasive procedures for low back pain in 2008.

"There are many options for evaluation and treatment of low back pain," said Amir Qaseem, MD, PhD, MHA, senior medical associate in the ACP Department of Clinical Programs and Quality of Care, and an author of the guidelines. "We wanted to review all the evidence and develop guidance for clinicians and to give our patients a realistic sense of what they can expect when they visit a clinician for low back pain. It is important to tell patients about their expected course based on evidence-based information and advise them to remain active."

Roger Chou, head of the American Pain Society Clinical Practice Guidelines Program, an author of the guidelines, and the senior author of the two background papers on which the guidelines were based, reviewed evidence for both drug therapies and non-drug therapies for acute and chronic low back pain.

"Almost all medications reviewed had some benefits, but they have risks," Chou said. "Acetaminophen, for example, is very safe but might not be effective. NSAIDS have gastrointestinal and cardiovascular risks. Opioids and muscle relaxers can provide relief for those with severe pain, but their potential benefits and risks should be weighed carefully."

"Patients who prefer not to take medication can benefit from non-drug treatments, such as acupuncture, spinal manipulations and massage therapy. None, however, are proven to be more effective than others to warrant recommendation as first-line therapy."

The following will be published in the in the October 2, 2007, edition of Annals of Internal Medicine and will be available to the public at www.annals.org:

"Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society,"

"Medications for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline"

"Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline"

Doctors learn to shut down the part of the brain that empathises with the pain their patients suffer during treatment, so they can avoid becoming distressed by conducting unpleasant medical procedures.

Brain scans have revealed that doctors show a different pattern of neural activity to other people when watching videos of painful therapies.

The findings indicate that medical training and experience allows them to override the normal human response to seeing others' suffering, which would otherwise hinder their ability to treat patients.

The research, led by Jean Decety, Professor of Psychology and Psychiatry at the University of Chicago, and Yawei Chang of the Taiwan Institute of Neuroscience, could also shed light on humanity's capacity for cruelty.

While the study did not test psychopaths, torturers or war criminals, it is possible that such people also have a genetic or learnt ability to suppress brain circuits that would normally lead them to empathise with their victims.

It is well known from previous research, some led by Professor Decety, that the parts of the brain that register pain can be activated vicariously by seeing another person suffering. While viewers do not necessarily then feel pain themselves, it often leads to a "flinch" or "panic" response.

This can often be beneficial, and may have evolved as a way of avoiding danger and aggressive actions that might put the viewer at risk from retaliation. In a medical context, however, it can be counterproductive.

Many therapies require doctors to conduct examinations, perform operations or administer drugs that will be uncomfortable, painful or distressing to their patients. A normal reaction to inflicting this pain would limit their capacity to treat people.

The new research suggests that they have learnt to control this, to allow them to do their jobs more effectively. "They have learnt through their training and practice to keep a detached perspective," Professor Decety said.

"Without such a mechanism, performing their practice could be overwhelming or distressing and, as a consequence, impair their ability to be of assistance for their patients."

In the study, published in the journal Current Biology, the scientists recruited 14 doctors, half male and half female, with an average age of 35. They then assembled a control group of people without medical training, who were matched for age, sex and socio-economic status.

All then had their brains scanned using functional magnetic resonance imaging (fMRI) while watching two videos. In the first, the participants saw patients having acupuncture needles in their mouth, hands and feet, a potentially painful procedure. In the second, they watched the same parts of the body being prodded with cotton buds.

During the pain videos, the control group showed higher activity in parts of the brain called the anterior insula, the periaqueductal grey and the anterior cingulate cortex. These are all known to be involved in the sympathetic pain response. The circuit did not respond during the cotton bud video.

Such raised activity was completely absent when doctors watched both videos. Instead, when doctors watched the pain video they showed increased activity in the medial and superior parts of the prefrontal cortex, regions that are known to be involved in controlling emotions.

Both groups were also asked to rate the level of pain felt by the subjects in the acupuncture video, on a scale of one to ten. The control group recorded an average of seven points, against three for the doctors, indicating that doctors tend to think of such procedures as less painful than the public at large.

The scientists said the phenomenon appears to be a learnt response to an instinctive brain reaction that would normally impair medical practice.

"It would not be adaptive if this automatic sharing mechanism for pain was not modulated by cognitive control," they wrote. "Think, for instance, of the situations that surgeons, dentists, and nurses face in their everyday professional practices.

"Without some regulatory mechanism, it is very likely that medical practioners would experience personal distress and anxiety that would interfere with their ability to heal."

Tuesday, October 09, 2007

What does feeling a sharp pain in one's hand have in common with seeing a red apple on the table? Some say not much, apart from the fact that they are both conscious experiences. To see an object is to perceive an extramental reality--in this case, a red apple. To feel a pain, by contrast, is to undergo a conscious experience that doesn't necessarily relate the subject to an objective reality. Perceptualists, however, dispute this. They say that both experiences are forms of perception of an objective reality. Feeling a pain in one's hand, according to this view, is perceiving an objective (physical) condition of one's hand. Who is closer to truth?

Because of such metaphysical issues, the subjectivity of pains combined with their clinical urgency raises methodological problems for pain scientists. How can a subjective phenomenon be studied objectively? What is the role of the first-person method (e.g., introspection) in science? Some suggest that the subjectivity of pains (and of conscious experiences in general) is due to their metaphysical irreducibility to purely physical processes in the nervous system. Can this be true?

The study of pain and its puzzles offers opportunities for understanding such larger issues as the place of consciousness in the natural order and the methodology of psychological research. In this book, leading philosophers and scientists offer a wide range of views on how to conceptualize and study pain. The essays include discussions of perceptual and representationalist accounts of pain; the affective-motivational dimension of pain; whether animals feel pain, and how this question can be investigated; how social pain relates to physical pain; whether first-person methods of gathering data can be integrated with standard third-person methods; and other methodological and theoretical issues in the science and philosophy of pain.

Wednesday, October 03, 2007

The world's hottest work in anesthesiology is being done at Harvard, where researchers are pouring pepper on pain.

Scientists at Harvard Medical School and Massachusetts General Hospital today described a new "targeted" approach to anesthesia that appears to totally block pain neurons, but doesn't cause the numbness or partial paralysis that is the unwelcome side-effect of anesthesia used for surgery performed on conscious patients.

If approved for use in humans, the method could dramatically ease the trial of giving birth -- by sparing women pain while allowing them to physically participate in labor. It could also diminish the trauma of knee surgery, for instance, or the discomfort of getting one's molars drilled. Not only would there be no "ouch," there would be none of the sickening wooziness or loss of motor control that comes from standard forms of "local" anesthesia.

In time, the process might even be employed for major surgery on the heart and other organs, the researchers said. More prosaically, the work might also represent a breakthrough cure for the common itch.

The work on lab rats, described in the scientific journal Nature, breaks from the standard approach to local anesthesia, which usually involves anesthetics delivered by catheter tubes or injections that silence all neurons in a given region of the body, not just those that sense pain. Shutting down just the pain neurons means that patients could still feel a light touch and other non-hurtful sensations.

"This could really change the experience of, for example, knee surgery, tooth extractions, or childbirth," said Dr. Clifford Woolf, senior author of the study and a researcher in anesthesia and pain management at Mass. General. "The possibilities are almost endless."

Woolf collaborated with Bruce Bean, professor of neurobiology at Harvard Medical School, in research that employed surprisingly basic scientific principles as well as some unlikely ingredients -- capsaicin, the stuff that imparts "hot" to chili peppers, as well as an all-but-forgotten variation of a standard anesthesia, long dismissed as clinically useless.

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